The accommodation ladder weighs about 2700 kg and is supported at one end by the turntable. Because of the ladder's inclination, a major portion of the weight is borne by the falls, acting at the point of suspension. This weight, via the snatch blocks and their fittings, is eventually transmitted to the winch drum. A deployed gangway, the bottom platform of which rests on the dockside, withstands a large amount of wear and tear. It has to compensate for the constantly changing vertical distance between the jetty and the ship's deck, under the influence of different conditions of loading, ballast, tide, and the wake of passing ships. The bottom platform is mounted on a roller, which allows the gangway to change its inclination smoothly, as the vessel's freeboard changes. The gangway also has to clear shore obstructions, such as bollards, capstans, and mooring lines. From its deployed position, the ladder is raised until it bears against its stops. The total load on the falls and thence on the deck fittings, at this stage, includes the weights of the ladder and the davit arm, as well as the frictional resistance in the sheaves, snatch blocks, and hinges. In its stowed position, the accommodation ladder lies inboard of the ship's side but outside of the railings. Its underside faces away from an inspector, and there is a clear drop of about 15 m on the other side. The vulnerable parts of the ladder, the davit arm, and the turntable are thus difficult to access. Inspection of the broken pad eye revealed two pre-existing cracks that had formed some time ago. The cracks were on the inside curvature of the pad eye and had escaped detection during preventive maintenance. The pad eye was subjected to repeated, nonuniform loading and unloading as the gangway was lowered and raised. Initially, the cracks were two points of stress concentration that slowly became enlarged, one of which had extended to almost 25% of the cross-sectional area of the pad eye. The failure occurred as a result of tensile overload when the remaining intact area was insufficient to carry the load imposed on it. Figure 3. View of broken pad eye. Dark areas in the cross section show the pre-cracks. Figure 4. View of broken pad eye.Analysis The accommodation ladder weighs about 2700 kg and is supported at one end by the turntable. Because of the ladder's inclination, a major portion of the weight is borne by the falls, acting at the point of suspension. This weight, via the snatch blocks and their fittings, is eventually transmitted to the winch drum. A deployed gangway, the bottom platform of which rests on the dockside, withstands a large amount of wear and tear. It has to compensate for the constantly changing vertical distance between the jetty and the ship's deck, under the influence of different conditions of loading, ballast, tide, and the wake of passing ships. The bottom platform is mounted on a roller, which allows the gangway to change its inclination smoothly, as the vessel's freeboard changes. The gangway also has to clear shore obstructions, such as bollards, capstans, and mooring lines. From its deployed position, the ladder is raised until it bears against its stops. The total load on the falls and thence on the deck fittings, at this stage, includes the weights of the ladder and the davit arm, as well as the frictional resistance in the sheaves, snatch blocks, and hinges. In its stowed position, the accommodation ladder lies inboard of the ship's side but outside of the railings. Its underside faces away from an inspector, and there is a clear drop of about 15 m on the other side. The vulnerable parts of the ladder, the davit arm, and the turntable are thus difficult to access. Inspection of the broken pad eye revealed two pre-existing cracks that had formed some time ago. The cracks were on the inside curvature of the pad eye and had escaped detection during preventive maintenance. The pad eye was subjected to repeated, nonuniform loading and unloading as the gangway was lowered and raised. Initially, the cracks were two points of stress concentration that slowly became enlarged, one of which had extended to almost 25% of the cross-sectional area of the pad eye. The failure occurred as a result of tensile overload when the remaining intact area was insufficient to carry the load imposed on it. Figure 3. View of broken pad eye. Dark areas in the cross section show the pre-cracks. Figure 4. View of broken pad eye. Inspection Regulations The International Convention on the Safety of Life at Sea, 1974 (SOLAS) does not address requirements for the installation, examination, or testing of accommodation ladders and their rigging. Classification societies and flag states do not have rules for their inspection or survey. Some classification societies have established criteria for the construction and the installation of new accommodation ladders on new vessels, but none for their continuous or periodic survey. Consequently, inspectors for a flag state, port state, or classification society may make a cursory observation of the accommodation ladder when boarding a vessel. Any defects or deficiencies in an accommodation ladder, especially those not readily observable, that could affect the safety of personnel may remain undetected. Time constraints due to an exigent loading or unloading schedule, coupled with the position and the stowage of the ladder, make a thorough on-site examination of the ladder difficult, especially of the parts subject to wear and tear. Vulnerable parts of the turntable (its pivot pin and bush), davit arm, sheaves, and bushings, hoist motor and gearing and braking arrangements, and other internal components of the accommodation ladder can only be inspected after disassembly. Like all vessels with freeboards greater than 9 m, the Alligator Victory was equipped with another two accommodation ladders, positioned midships, that formed part of the pilot transfer arrangement. Under the IMO inspection regime, accommodation ladders used for pilot transfer are subject to inspection as part of the Safety Equipment Certificate requirement.2 Therefore, some accommodation ladders on some vessels are subject to inspection, whereas those on other vessels are not. The IMO recognizes the need to inspect the accommodation ladder. Such inspection, however, is limited to ladders used for pilot transfer and does not extend to all accommodation ladders on a vessel. Regulation 25(4) of the 1966 International Load Line Convention states that satisfactory means (in the form of . . . gangways . . .) shall be provided for the protection of the crew in getting to and from their quarters . . . and other parts used in the necessary work of the ship. There is no corresponding requirement for safe access to, and egress from, the ship itself. Articles 3, 3.1.1, and 3.1.2 of the International Labour Organization's Code of Practice entitled Safety and Health in Dock Work stipulate that safe means of access to, and egress from, the vessel should be provided. The document places preference on a ship's accommodation ladder. However, no reference is made to the inspection requirement by a competent authority. Thus, accommodation ladders-used by crew members, officials, stevedores, and visitors-are not subject to inspection as part of a survey regime except when used for pilot transfer. The absence of a mandated inspection of accommodation ladders allows potentially unsafe ladders to be used as a means of access to and egress from the vessel. In Canada, inspection of accommodation ladders may be carried out under the provisions of the Tackle Regulations3 or the Marine Occupational Health and Safety Regulations.4 The Tackle Regulations deal with cargo-handling equipment and safe access to and egress from vessels. While they prescribe formal inspection, testing, and recordkeeping of cargo-handling equipment, they do not prescribe such a regime for accommodation ladders. Hence, under the current system, with no defined set of rules, examination of ladders may be no more than perfunctory and subjective, depending on an inspector's experience and knowledge. Other Occurrence and Classification Society Inspection The Arabella had changed its classification society from Nippon Kaiji Kyokai to the Korean Register of Shipping in 1994. Since the accommodation ladder was not subject to inspection, no information on the state of the ladder was recorded, nor did the new classification society conduct a survey of the ladder at the time of, or subsequent to, the change in classification society. As a result, the less-than-satisfactory condition of the ladder went undetected, compromising the safety of personnel, and remained undetected until the accident. ISM Certification and Safety The vessel was working toward obtaining a Safety Management Certificate and had a voluntary safety management system in place to comply with the ISM Code requirements. The vessel's management company was issued a Document of Compliance by Nippon Kaiji Kyokai. safety sensitive equipment such as accommodation ladders be inspected at appropriate intervals nonconformities be reported to the head office remedial measures be taken to remove nonconformities a record of these activities be maintained Nevertheless, the safety management system documentation on the maintenance of accommodation ladders made no reference to those safety-critical parts that are subject to wear and tear. The pad eye securing the snatch block-through which the falls were reeved-parted and released the snatch block. The snatch block then violently hit in the forehead a crew member, who succumbed to his injuries. The pad eye broke in two; the failure was caused by shear from tensile overload. The pad eye was found to be cracked in two places. (These cracks were previously formed and had slowly become enlarged.) One of these cracks extended to about 25% of the cross-sectional area of the pad eye. The vessel's planned maintenance had failed to identify the existence of these two cracks.Findings as to Causes and Contributing Factors The pad eye securing the snatch block-through which the falls were reeved-parted and released the snatch block. The snatch block then violently hit in the forehead a crew member, who succumbed to his injuries. The pad eye broke in two; the failure was caused by shear from tensile overload. The pad eye was found to be cracked in two places. (These cracks were previously formed and had slowly become enlarged.) One of these cracks extended to about 25% of the cross-sectional area of the pad eye. The vessel's planned maintenance had failed to identify the existence of these two cracks. Under the current regulatory regime-international, flag state, or classification society-accommodation ladders used by pilots are subject to periodic inspection and survey. Accommodation ladders that are not used for pilot transfer but that constitute the main means of access to and egress from a ship are not subject to this requirement. This exposes individuals boarding and exiting the vessel to risk, precludes audit of maintenance records, and permits the continued use of ladders that may be unsafe.Findings as to Risk Under the current regulatory regime-international, flag state, or classification society-accommodation ladders used by pilots are subject to periodic inspection and survey. Accommodation ladders that are not used for pilot transfer but that constitute the main means of access to and egress from a ship are not subject to this requirement. This exposes individuals boarding and exiting the vessel to risk, precludes audit of maintenance records, and permits the continued use of ladders that may be unsafe. Safety Action Taken